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The geniculate ganglion (“external genu”) is located within the temporal bone. The first branch from the ganglion is the greater superficial petrosal nerve (GSPN) which passes to the pterygopalatine ganglion and innervates the nasal and palatine mucosa and the lacrimal gland of the eye; lesions proximal to this point produce a dry eye.

The greater (superficial) petrosal nerve carries parasympathetic preganglionic fibers from the facial nerve. The greater petrosal nerve continues as the nerve of the pterygoid canal and ultimately synapses with the pterygopalatine ganglion whose parasympathetic postganglionic fibers synapse with the lacrimal gland and the mucosal glands of the nose, palate, and pharynx.

The greater superficial petrosal nerve (GSPN) is especially important in anterior transpetrosal approach (ATPA) as the most reliable superficial landmark of Kawase's triangle. The GSPN can be considered as the superficial lateral border of anterior petrosectomy on the middle fossa to avoid internal carotid artery (ICA) injury. Although experienced operators can find the GSPN, its confirmation is not always easy to achieve.

In 10 recent cases, antidromic GSPN stimulation and free-running facial muscle electromyography (EMG) monitoring were performed.

Facial nerve evoked-EMG by antidromic GSPN stimulation confirmed the location of the GSPN course with precision in all cases. Free-running facial muscle EMG informed the mechanical stress of facial nerves through the GSPN. There was no postoperative facial palsy or dry eye in these cases.

GSPN confirmation and preservation are not always easy to achieve. These monitoring methods are useful for the confirmation of the GSPN, which is a landmark for safe extradural anterior petrosectomy, and for the preservation of the GSPN itself ¹⁾.